Anatomy of the Great Adderall Drought

Last May, Stephanie Lee couldn’t find a pharmacy in Atlanta that stocked Adderall, the prescription drug cocktail of amphetamine salts that helps her treat her attention deficit hyperactivity disorder, or ADHD. She called her local pharmacy. All amphetamine salts, as well as generic, extended release Adderall XR were nowhere to be found, thanks to a limit set on the amount of amphetamines produced every year by the federal government.

Luckily, Stephanie’s insurance covered name-brand Adderall XR, so she was still intermittently able to get her prescription filled. At one point, she was trading some XR pills with her sister-in-law for amphetamine salts because pharmacies were all out. Another time, she went a month and a half without any medication at all. Signs started popping up at pharmacies saying, “No Adderall available until 2012.”

When the shortage began, Stephanie had just begun a new job. I asked her how she functioned without her medication. She compared concentrating off of Adderall to the feeling of “someone who used to be super thin and fit who gains a ton of weight and then tries to run a marathon. Only imagine the weight gain happening overnight. You’re like, ‘Fuck! I just did this yesterday! Why is it so much harder now?’”

Today, Adderall is only legal in the United States and Canada. Currently there’s a massive shortage of it in the U.S., leaving many ADHD sufferers like Stephanie without access to medication and leaving others stuck paying for higher-priced alternatives.

Everybody’s favorite focus drug

For many people with ADHD, Adderall is what best manages their symptoms. At the same time, a drug that reduces appetite, increases wakefulness, induces feelings of euphoria (side effects, or, rather, effects of Adderall)—all through flooding your brain’s reward system—has vast potential for abuse. Amphetamine salts, used in Adderall, are classified by the U.S. Government as a Class II Narcotic, the same as cocaine and Oxycontin.

To prevent hoarding of materials and their potential for theft and illicit use, the Drug Enforcement Agency sets quotas for the chemical precursors to drugs like Adderall. The DEA projects the need for amphetamine salts, then produces and distributes the materials to pharmaceutical companies so that they can produce their drugs. But with the number of prescriptions for Adderall jumping 13 percent in the past year, pharmaceutical companies claim that the quotas are no longer sufficient for supplying Americans with their Adderall.

ADHD affects a startling number of Americans—it’s estimated that nearly five percent of Americans are living with the disorder. Many of those affected use some type of stimulant drug to treat their symptoms. While various drug treatments—notably methylphenidate, better known as Ritalin—have been around since the early 1960s, the Jersey-registered, Ireland-headquartered global specialty biopharmaceutical company, Shire Pharmaceuticals’ introduction of Adderall in 1996 drastically changed the landscape of ADHD treatment. Today, only generic versions of the mixture of amphetamine salts are available. However, the extended release form, Adderall XR, is available in both generic and name-brand forms.

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Despite the millions of prescriptions written each year for ADHD, the scientific community isn’t entirely in agreement on how these drugs actually work. Ritalin increases focus and energy through inhibiting the re-uptake of both dopamine and norepinephrine in the brain. These neurotransmitters then remain in the synapse longer, and their effects are felt in the form of heightened focus and awareness. Adderall, however, works via a slightly different mechanism. While it’s postulated that Adderall also inhibits the re-uptake of these same neurotransmitters, amphetamines also trigger the release of dopamine. This affects the brain’s reward mechanisms, so it’s not only easier to focus on mundane or repetitive tasks, it can also feel positively delightful to do so.

Without Adderall, you might feel bored by your math homework or unable to focus on the multiple steps needed to reach a solution, but on Adderall you might literally feel like you’re in love with math. The tricky thing about prescribing stimulant medications is that, ostensibly, the drugs will achieve their purpose (increased concentration and motivation) in pretty much anyone, regardless of whether they have ADHD or not.

Quotas must be insufficient

Doctors wrote over 18 million prescriptions for Adderall in 2010, and that number escalates every year. Increasing numbers of Americans being diagnosed with ADHD, coupled with a surge of others either feigning symptoms to get prescriptions or drying out their prescribed friends’ supplies, means there’s simply not going to be enough Adderall to satisfy everyone’s needs (and desires).

It’s well known that many college students use Adderall to give themselves an extra edge for getting work done whether they’re prescribed or not. A 2005 study of students attending 119 colleges nationwide found that, on certain campuses—regardless of whether or not they had prescriptions—up to 25 percent of respondents had misused ADHD medications. Furthermore, a 2009 study on non-medical use (defined as use of a prescription drug without a doctor’s order) of Adderall among full-time college students showed that subjects aged 18 to 22 were twice as likely as their counterparts, who were not full-time college students, to have used Adderall.

The DEA contends that their quotas do, in fact, meet demands, and that any shortages arise from pharmaceutical companies selectively producing only certain (typically name-brand) versions of ADHD medications. Yet it would seem that the quotas must be insufficient.

Everyone I talked to about the Adderall shortage reported not being able to find generic or name-brand versions of their medication. I spoke with three people personally affected by the shortage, and they said that at times, there was literally nothing available anywhere.

“Why is this so much harder now?”

First I spoke with David, thirty-two. He was diagnosed with ADHD eight years ago, and was prescribed Adderall, but had taken it infrequently until this year. This past September, when he returned to school to pursue a Master’s degree, he began taking his medication daily for the first time. In only four months, he found himself manic, hypersexual, jittery, and feeling “crazy.” He craved cigarettes and coffee, began having difficulty sleeping and, ironically enough, concentrating.

In the face of diminishing availability of the drug, matched with his extreme response, he opted to change medications entirely and switched, recently, to a newer ADHD medication, Vyvanse. Though he hasn’t been taking it long, he claims that the new medication has helped him focus while also helping him remain calm. But it’s when we start talking about Vyvanse that things start getting even more complicated. We’ll get that to that a bit later.

Stephanie Lee found her freshman year of college unusually difficult. She had trouble adjusting to the levels of stress she encountered. Additionally, her mother, two brothers, and her sister had all been recently diagnosed with ADHD, so she, very reasonably, wondered if she might also have the disorder. Beginning in her sophomore year, armed with a prescription from her doctor, she took a combination of Adderall XR and amphetamine salts throughout college, and then completely ceased taking ADHD medication all together for a few years.

But she went back on the medication when she returned to school for a graduate program. She began taking the same combination of drugs she had as an undergraduate and was doing well until May 2011, when her pharmacy called to inform her that the 20 milligram Adderall XR pills she usually took were out of stock. In the eight months that followed, Stephanie switched to two 10 milligram pills of Adderall XR (the only dosage available) twice per day. Despite being the same total number of milligrams, taking the drugs this way was twice as expensive, so Stephanie soon had to pay her costly health insurance deductible, something that had never happened to her before.

Hilary, twenty-six, was the one person I spoke with who had not been diagnosed with ADHD in adulthood. She began taking ADHD medications when she was five, and continued, basically uninterrupted until the Adderall shortage. Hilary lost her health insurance earlier this year. Unfortunately, this coincided with the beginning of the Adderall shortage. Suddenly, the generic version, which typically costs around thirty dollars for a month’s supply, was gone. She was left forking over three hundred dollars for a month’s supply of the name-brand medication, or simply going without. Hilary has now been off of her medication for two months and mentions she’s in the market for a sugar daddy to help her foot her medication bills. She’s only half joking.

When I asked Stephanie about dealing with life off Adderall, she remarked that she “wasn’t one of those kids who grew up on the stuff. I hadn’t been diagnosed until much later in my life, so I knew how to get by.” But what about kids like Hilary, who have literally gone their entire lives medicated? Regardless of the legitimacy of ADHD and stimulant medications, it’s impossible to ignore the fact that those accustomed to medication will fare worse when off of it, at least for some period of time or, as in David’s case, until they are prescribed something else, like Vyvanse.

Supplying the Competition

In 2006, two pharmaceutical manufacturers, Teva Pharmaceuticals and Impax Laboritories, were awarded the rights to sell generic versions of Adderall XR when Shire lost its patent in 2009. However, the drug manufacturers didn’t have the production capacity to produce such a large amount of drugs, and Shire was awarded a subcontract from the government to produce for the other manufacturers until they were able to on their own. Though they had lost their cash cow patents on Adderall and Adderall XR, Shire would continue to profit from their manufacturing generic forms of Adderall XR.

In the spring of 2009, after losing their patent on Adderall XR, Shire’s earnings predictably plummeted. Earnings for one quarter nosedived from $300 million to $67 million. But, oddly, in 2010, earnings began to creep upwards, surpassing $100 million in one quarter. Around this time, Impax and then Teva both filed lawsuits stating that Shire was intentionally botching their orders of generic Adderall XR, delivering too little of the drug or missing orders all together. Mysteriously, there still seemed to be enough brand name Adderall XR floating around to improve Shire’s profit margins. It would seem a simple lesson to not let a single entity produce both their own product and their chief competitor’s product, but that’s exactly what Shire was doing.

The DEA contends that shortages arise from pharmaceutical companies selectively producing only certain versions of medications

Oddly, around the same time, many insurance companies began to refuse to cover generic Adderall XR. Generic Adderall XR is not, in fact, FDA-approved to treat ADHD and insurance companies claimed that the therapeutic equivalence to Shire’s Adderall XR was unproven.

The results of the shortage or lack of insurance coverage for generic Adderall XR forced many people to seek out name-brand Adderall XR, which, in turn, ran out. Then people, desperate for any ADHD medication, sought out the generic instant release amphetamine salts (formally Adderall). The increased demand on instant release dried up the supplies pretty quickly, and soon ADHD sufferers everywhere were unable to find any form of their medication. Luckily, Shire had magically possessed enough amphetamines from their DEA quota to produce plenty of their new ADHD medication, Vyvanse. In fact, Shire doubled its third quarter profits from 2010 to 2011, with most of that increase resulting from Vyvanse sales. During this time, coinciding nicely with the Adderall shortage, Shire hiked the price of Vyvanse.

But, in medical trials Vyvanse proved no better at treating ADHD symptoms than generic Adderall XR. It’s not any easier to get either; its active chemical, Lisdexamfetamine, also a schedule II narcotic, precludes doctors from writing refills of the prescription. Add on that it’s much more expensive than either of the generic forms of amphetamine salts and its list of side effectsmirror those of Adderall. So, why would anyone switch to Vyvanse? The answer is that they wouldn’t, at least not in such large numbers. Not unless they had to.

So, is the DEA and its quota system really to blame for the shortage of drugs? Well, partially, yes. If the DEA didn’t restrict any manufacturer’s access to amphetamine salts, then everyone could manufacture Adderall in all of its versions, generic and name-brand, to their murmuring hearts’ content. But the government quotas are also a convenient scapegoat for pharmaceutical companies seeking to supply only the more expensive—and more profitable—of the ADHD medications.